Spine Pathology Dr Salameh Al dajah Dr. Salameh Al Dajah 2014
Learning Objectives Identify spine anatomy related to spine pathology Recognize intervertepral disc anatomy (IVD) Recognize different spine pathology seen by PT Recognize special test for different spine pathology Perform treatment plans for different spine pathology Dr. Salameh Al Dajah 2014
Pathology of the spine Introduction The lumbar spine functions as a complex interplay of musculoskeletal and neuro-vascular structures creating a mobile, yet stable, transition between the thorax and pelvis. The lumbar region repetitively sustains enormous loads throughout one’s life time, while still providing the mobility necessary to allow a person to perform multi-tasks associated with daily living. In addition, the lumbar spine provides the fibro-osseous pathway for the inferior portion of the spinal cord Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Classification of disorders of the low back Congenital abnormality Lumbar vertebrae variation (anomalies) Hmivertebra Spinabifida Deformities Scoliosis Hyperlordosis Kyphosis Infections of bone Tuberculosis Pyogenic infection Dr. Salameh Al Dajah 2014
Osteochondritis (the cartilage or bone in a joint is inflamed) Arthritis of the spine RA OA Ankylosing spondylitis Osteochondritis (the cartilage or bone in a joint is inflamed) Scheurman’s disease Dr. Salameh Al Dajah 2014
Mechanical derangements Prolapsed lumbar Intervertebral disc (IVD) Acute lumbago(disorder involving the muscles and bones) Spondylolysis(defect in the pars interarticularis of the vertebral arch) Spondylolisthesis Spinal stenosis(narrowing of spinal canal) Tumors Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Spondylolisthesis Dr. Salameh Al Dajah 2014
Chronic strains Miscellaneous Lumbar ligamentus strain Coccydynia, (pain in the coccyx) Miscellaneous Fibrositis Senile osteoporosis Dr. Salameh Al Dajah 2014
Pathology Hemi vertebra In this anomaly a vertebra is formed in one lateral half only. The defect may occur at any level of the spine. The body of the half –vertebra is wedge-shaped, and the spine is angled laterally at the site of the defect. This anomaly is a rare cause of scoliosis. Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Spina bifida The basic fault in spina bifida is a failure of the embryonic neural plate to fold over to form a closed neural tube, or of mesodermal tissue fully to invest the neural tube as it does in the normal embryo to form the vertebral arch with its spinous process, and the surrounding muscles and ligaments. Dr. Salameh Al Dajah 2014
Scoliosis Scoliosis, or lateral curvature of the spine, may be idiopathic, congenital, neuromuscular in origin. Idiopathic scoliosis is responsible for 85-95% of all cases of scoliosis. It is classified either structural or nonstructural (temporary or compensatory). Dr. Salameh Al Dajah 2014
Nonstructural curves are flexible and readily correct with side bending. It is may be due underlying disorder or a result of muscle spasm due low back pain The diagnosis will be made by general physical examination to the alignment of the spine (Adam’s positions), and confirmed by standing plain x-ray film. The spine may appear in S or C shape. Dr. Salameh Al Dajah 2014
When the scoliotic curvature disappears in the adam’s position, the curves are mild to moderate, or less than 25 degrees. These curves have more of functional components than structural component and are amenable to conservative management. Dr. Salameh Al Dajah 2014
Treatment 1. Surgical 2. Conservative: this form of management utilize therapeutic exercises and braces A. stretching exercise B. Mobility exercise C. Postural training D. Breathing and chest expansion training E. Use braces like Milwaukee distraction brace Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Hyper Lordosis Para vertebral Muscle spasm Tightness of hamstring Weakness of the lower abdominal muscles Dr. Salameh Al Dajah 2014
Lordosis Dr. Salameh Al Dajah 2014
Ankylosing spondylitis This is a condition affects spinal column in all three regions. There is a chronic inflammation progressing slowly to bony ankylosis of the joints of the spinal column and occasionally of the major limb joints. It is a flexion deformity in the spinal column. Usually start at the sacroiliac joint Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Complications Permanent stiffness Fixed flexion deformity of the spine Recurrent respiratory infection Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Special test Most effective method for diagnosis is through assessing spine ROM and by X-ray, A calcification connection between the vertebrae will be noted in the X-ray. Dr. Salameh Al Dajah 2014
Treatment Treat the symptoms (localized pain) Maintain activity encourage extension exercise Active and positioning exercise to stretch shortened anterior ligaments Hydrotherapy may be the best modality followed by extension exercise In addition, patient need Non-steroidal anti inflammatory drugs prescribed by his doctor Dr. Salameh Al Dajah 2014
Scheuermann’s vertebral Osteochondritis The vertebral bodies ossify from three centers. A primery center at the middle of the vertebral body, and secondary centers at the upper and lower surfaces. These secondary centers, known as the ring epiphyses, appear at about the time of puberty in the cartilaginous end-plates that separate the vertebral bodies from the adjacent intervertebral disc. Dr. Salameh Al Dajah 2014
Diagnosis and Treatment Diagnosis by X-ray and history of the symptoms Treatment may include Rest to avoid stress fracture of the vertebral body Braces to protect the affected segments Strengthening exercises for the back muscle (extension exercises) Dr. Salameh Al Dajah 2014
Lumbar Intervertebral disc prolapse The Intervertebral disc is the source of most low back pain. Of disc lesions in the lumbar spine, 95% occur at the fourth and fifth spaces. With normal aging and repetitive trauma, progressive degeneration of the nucleus pulpous occurs. The disc protrusion of a young adult is likely to be traumatic. Protrusion of nuclear material usually occurs in the area of greatest weakness at the posterior-lateral aspect of the disc Dr. Salameh Al Dajah 2014
the compression may affect on the cauda equine. If the protrusion at the midline, roots on both sides may be involved If it is large enough, the compression may affect on the cauda equine. Pain in the segmental distribution of a root is the hall-mark of root compression syndrome. Pain in the spine and restriction of spinal movement are common Dr. Salameh Al Dajah 2014
Pain that radiates down the leg follows the primary anterior division of the nerve and may be localized by the patient anywhere in the distribution of the root. This root pain is aggravated by spinal movement, like rolling in the bed. Pain is also aggravated by local pressure over the nerve or the muscle and after prolonged sitting. Parasthesia in root distribution is common and usually experienced distally in the foot. Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Treatment Muscle relaxing through different modalities Extension exercise (Meckinzy exercise) Postural training Limit the extension exercise if there is a facet joint (Z Joint) involvement Instruct patient to limit his sitting posture and encourage walking Patient may benefit from hydrotherapy Patient may benefit from strengthening of the back muscles Avoid manipulation in the acute stage Bed rest may help at the acute stage Advise patient when he lies down to bend the hip and knees to keep the back muscle relaxed. Dr. Salameh Al Dajah 2014
Spondylolisthesis Congenital Spondylolisthesis consist of structural anomalies of the lumbo-sacral junction resulting in inadequate mechanical support to prevent forward slipping of L5 on S1 vertebra. It may be due traumatic fracture of the spinous process of L5 as a result of a fall from a height or due degenerative changes involved the facet joint and the disc material. Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Treatment Hydrotherapy to improve muscle spasm Abdominal strengthening exercise (William flexion exercise) Avoid spine extension exercise or activities involving extension Dr. Salameh Al Dajah 2014
Assessment and management for cervical spine conditions Cirvical Spine Assessment and management for cervical spine conditions Dr. Salameh Al Dajah 2014
Cervical rib It is a congenital overdevelopment of the costal process of the seventh cervical vertebra The subclavian artery and the lowest trunks of brachial plexus arch over the first rib, and may be squeezed and damaged. The motor symptoms may include Dr. Salameh Al Dajah 2014
Pathology The subclavian artery bends over and passes through a sulcus in the first rib. Brachial plexus lies stretched and lies tautly without bony protection in this region. Anterior scalene syndrome and the costoclavicular syndrome (cervical rib) compression are two conditions recognized as thoracic outlet syndrome. X -ray is essential to determine the presence of the cervical rib, but it is not a prove that it is the cause of the symptoms. Dr. Salameh Al Dajah 2014
Symptoms weakness of the hand muscle Inability to perform fine movement Numbness at the lateral side of the hand and forearm Vascular manifestation ranges from cyanosis of the forearm to gangrene in the hand Sensory disturbances can occur in either a dermatome distribution or in the destruction of the peripheral nerves are suspected Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Cervical spondylosis Assessment History (increasing neck pain, may radiating to the upper extremities) Observe the neck posture (head forward, rounded shoulders) Palpation (M. Spasm, Swelling, Dislocation) ROM MMT Neurological tests Special tests Dr. Salameh Al Dajah 2014
Muscle spasm: It comes with any abnormality in the neck Muscle spasm: It comes with any abnormality in the neck. It is a protective reaction Indicated in X ray (Lateral view) by straightening of the spine and diminished the C curve in the neck. It causes limitation in all ROM, especially with rotation, flexion and hyper extension. Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Cervical disc prolapse General appearance Assessment Palpation Radiating pain, and numbness to the upper extremities Findings (AROM, MMT, Neurological tests, and special test Dr. Salameh Al Dajah 2014
Three levels of disc disease Normal disc protrusion/ prolapse Extrusion Sequestration Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Special tests Distraction test: Test for foramin encroachment and facet capsulitis Jackson compression test: Test for nerve root compression, space occupying lesions, DJD Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Jackson test procedure Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dejerine’s sign Procedure Coughing, sneezing, and straining during defecation may aggravate radiculitis symptoms This aggravation results from the mechanical obstruction of spinal fluid flow Dr. Salameh Al Dajah 2014
Treatment plan Muscle relaxation (modalities, isometric exercises), May use cervical traction and postural training, May involve manual mobilization if there is no osteophite May use cervical soft collar Dr. Salameh Al Dajah 2014
Treatment plan For Disc prolaps: may include Muscle relaxation to Include Intermittent traction in neutral position (manual or mechanical) Modalities (hot pack, US, IF, TENS, Use what is available) Muscle strengthening and ROM to Retain mobility (AROM to ARROM, isometric exercise, ) At the beginning use hard cervical collar Encourage patient to use suitable pillow when sleep Dr. Salameh Al Dajah 2014
Vertebral artery insufficiency Pathology Cervical muscle spasm cause neck straitening, which results in stretching and narrowing of the vertebral artery and decrease the blood flow to the posterior parts of the brain Dr. Salameh Al Dajah 2014
Symptoms Main complaint will include headache and dizziness in addition to the pain in the neck and upper trapezius due muscle spasm. X ray shows neck straightening at the level of C4-C7 due the muscle spasm Dr. Salameh Al Dajah 2014
Special tests Barre-Lieou sign Deklyn’s Dr. Salameh Al Dajah 2014
Barre-Lieou sign The examiner instructs the patient to slowly rotate the head from side to side while in seated position, or supine with the head extended out of the table (Hallpike maneuver) This maneuver will cause compression of the vertebral arteries Vertigo, dizziness, visual disturbances, nausea, syncope, and nystagmus are signs of positive test A positive findings strongly indicate a buckling of the ipsilateral vertebral artery Dr. Salameh Al Dajah 2014
Dekleyn’s test procedure With the patient in the supine position and the patient head off the table, the examiner instruct patients to hyperextend and rotate the head and hold this position for 15-45 seconds, repeat this maneuver to the other side Vertigo, blurred vision, nausea, syncope, and nystagmus are signs of positive test Dr. Salameh Al Dajah 2014
Treatment plan: may include Modalities for muscle relaxation Retain C curve By using special pillow, and extension mobilization for C4-C7 Avoid traction Manual mobilization to retain neck extension (normal posture) No need for cervical collar Encourage AROM, and isometric neck exercise (extension > flexion) Dr. Salameh Al Dajah 2014
Brachial plexus tension test The examiner passively elevate the patient’s shoulders through abduction the elbows are extended to a point just short of the onset of pain and are maintained in that position The shoulders are externally rotated to the point just short of the onset of pain and maintained Reproduction of symptoms suggests cervical spine disorders, most likely C5 nerve root When flex cervical spine from this position, symptoms will increase Dr. Salameh Al Dajah 2014
Bikele’s sign Procedure With the arm held upward and backward and the elbow fully flexed, the patient extends the elbow If such movement meets with resistance and increases ridiculer pain from the cervicodorsal region, the test is positive This sign indicate there is brachial plexus neuritis or meningitis because this maneuver stretches the brachial plexus nerve roots Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Cervical muscles,and ligament Pathology Wrhy neck: Derangement of the cervical facet joints as a result of sudden movement or sleeping on wrong position. The symptoms may last 3-4 days Whiplash: sudden and fast neck movement forward and backward (acceleration and deceleration), which may cause ligamentus and muscles strains or sprains. Symptoms may last for weeks and may worsen. It may cause acute c. disc prolaps. This is seen mostly in head to tail Car accidents. Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Dr. Salameh Al Dajah 2014
Five levels of neck Muscles and ligaments injuries Dr. Salameh Al Dajah 2014